Provider Demographics
NPI:1659446425
Name:DIGESTIVE AND LIVER CENTER OF MELBOURNE LLC
Entity Type:Organization
Organization Name:DIGESTIVE AND LIVER CENTER OF MELBOURNE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAGED
Authorized Official - Middle Name:DOSS
Authorized Official - Last Name:FARID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-752-5210
Mailing Address - Street 1:25 SILVER PALM AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3177
Mailing Address - Country:US
Mailing Address - Phone:321-725-4150
Mailing Address - Fax:321-733-1335
Practice Address - Street 1:25 E SILVER PALM AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3177
Practice Address - Country:US
Practice Address - Phone:321-725-4150
Practice Address - Fax:321-733-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1165261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075356400Medicaid
FLF1393Medicare ID - Type Unspecified